Healthcare Provider Details

I. General information

NPI: 1417871013
Provider Name (Legal Business Name): BLOOM PRIMARY MO II, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2026
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 MARYVILLE CENTRE DR STE 340
SAINT LOUIS MO
63141-5831
US

IV. Provider business mailing address

12600 W COLFAX AVE STE 200
LAKEWOOD CO
80215-3733
US

V. Phone/Fax

Practice location:
  • Phone: 303-993-1330
  • Fax:
Mailing address:
  • Phone: 303-993-1330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DEBRA KAY MOON WADELTON
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 720-923-1250